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Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing?
Michael Hunter Culbert1, Adam Nelson1, Omar Obaid1
1Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States.
Insights
Emergent trauma laparotomies in children have high mortality and failure-to-rescue rates. Younger age, head injury, and early blood transfusions are linked to worse outcomes in pediatric trauma surgery.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Surgical Outcomes Research
Background:
- Emergent trauma laparotomy carries a significant mortality risk (up to 40%).
- Limited data exists on outcomes for pediatric patients undergoing emergent laparotomy.
- This study addresses the need to understand pediatric trauma laparotomy outcomes and failure-to-rescue (FTR) factors.
Purpose of the Study:
- To describe outcomes, including mortality and FTR, in pediatric trauma patients undergoing emergent laparotomy.
- To identify factors associated with failure-to-rescue (FTR) in this population.
- To inform quality improvement initiatives for pediatric trauma care.
Main Methods:
- Retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset (2017).
- Included pediatric trauma patients (<18 years) undergoing emergent laparotomy (within 2 hours of admission).
- Multivariate regression analysis identified factors associated with FTR (death after major in-hospital complication).
Main Results:
- 462 pediatric patients underwent emergent laparotomy; overall mortality was 21%.
- Failure-to-rescue (FTR) rate was 31% among those with major in-hospital complications.
- Factors associated with FTR included younger age (<8 years), severe head injury, and early packed red blood cell transfusion.
Conclusions:
- Pediatric emergent trauma laparotomies are associated with high morbidity, mortality, and FTR rates.
- Quality improvement programs should focus on preventing in-hospital complications and refining resuscitation.
- Findings highlight critical areas for enhancing pediatric trauma care protocols.
Introduction:
Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR).
Methods:
We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age <18 years) who underwent emergent laparotomy (laparotomy performed within 2 h of admission) were included. Outcome measures were major in-hospital complications, overall mortality, and failure-to-rescue (death after in-hospital major complication). Multivariate regression analysis was performed to identify factors independently associated with failure-to-rescue.
Results:
Among 120,553 pediatric trauma patients, 462 underwent emergent laparotomy. Mean age was 14±4 years, 76% of patients were male, 49% were White, and 50% had a penetrating mechanism of injury. Median ISS was 25 [13-36], Abdomen AIS was 3 [2-4], Chest AIS was 2 [1-3], and Head AIS was 2 [0-5]. The median time in ED was 33 [18-69] minutes, and median time to surgery was 49 [33-77] minutes. The most common operative procedures performed were splenectomy (26%), hepatorrhaphy (17%), enterectomy (14%), gastrorrhaphy (14%), and diaphragmatic repair (14%). Only 22% of patients were treated at an ACS Pediatric Level I trauma center. The most common major in-hospital complications were cardiac (9%), followed by infectious (7%) and respiratory (5%). Overall mortality was 21%, and mortality among those presenting with hypotension was 31%. Among those who developed in-hospital major complications, the failure-to-rescue rate was 31%. On multivariate analysis, age younger than 8 years, concomitant severe head injury, and receiving packed red blood cell transfusion within the first 24 h were independently associated with failure-to-rescue.
Conclusions:
Our results show that emergent trauma laparotomies performed in the pediatric population are associated with high morbidity, mortality, and failure-to-rescue rates. Quality improvement programs may use our findings to improve patient outcomes, by increasing focus on avoiding hospital complications, and further refinement of resuscitation protocols.
Level Of Evidence:
Level IV STUDY TYPE: Epidemiologic.
